WCB Case Number (if known): Balance Due (Carrier Use Only) Amount Paid (Carrier Use Only) Total Charge Use WCB Codes $ Dates of Service From MM DD YY To MM DD YY Place of Service Leave Blank Procedures, Services or Supplies CPT/HCPCS MODIFIER Diagnosis Code $ Charges Days/ Units COB Zip code where service was rendered $ $ 3. WCB Rating Code: 1. Your name: 2. WCB Authorization #: SSN EIN Number and Street 5. Office address: City 7. Billing address: State Zip Code 4. Federal Tax ID #: B. Doctor's Information The Tax ID # is the (check one ): Zip Code State City Number and Street Use this form to report continuing services. (To report the first time you treated the patient, use Form C-4. To report permanent impairment, use Form C-4.3.) Doctor's Progress Report 4. Diagnosis or nature of disease or injury: Enter ICD10 Code: ICD10 Descriptor: (1) (2) (3) (4) C. Billing Information Relate ICD10 codes in (1), (2), (3), or (4) to Diagnosis Code column below by line. Check here if services were provided by a WCB preferred provider organization (PPO). C-4.2 Date(s) of Examination: ______________________________________________________________________________________________ Last First MI Please answer all questions completely, attaching extra pages if necessary, and submit promptly to the Board, the insurance carrier and to the patient's attorney or licensed representative, if he/she has one; if not, send a copy to the patient. Failure to do so may delay the payment of necessary treatment, prevent the timely payment of wage loss benefits to the injured worker, create the necessity for testimony, and jeopardize your Board authorization. You may also fill out this form online at www. wcb.ny.gov. 2. Date of injury/illness: _____/_____/_____ 3. Soc. Sec. #: 1. Name: A. Patient's Information Last First MI - - Number and Street Zip Code State City 4. Address (if changed from previous report) : www.wcb.ny.gov C-4.2 (10-15) Page 1 of 2 Number and Street 1. Employer's insurance carrier: 3. Insurance carrier's address: Zip Code State City 2. Carrier Code #: W 5. Patient's Account #: 1. Describe any diagnostic test(s) rendered at this visit: _______________________________________________________________________ D. Examination and Treatment Carrier Case Number (if known): 8. Office phone #: (______)_____________ 10. Treating Provider's NPI #: 9. Billing phone #: (______)______________ 6. Billing Group or Practice Name:
Transcript
WCB Case Number (if known):
Balance Due (Carrier Use Only)
Amount Paid (Carrier Use Only)
Total Charge
Use WCB Codes
$
Dates of ServiceFrom
MM DD YY To
MM DD YY
Place of Service
Leave Blank
Procedures, Services or Supplies CPT/HCPCS MODIFIER
Diagnosis Code $ Charges Days/ Units
COB Zip code where service was rendered
$ $
3. WCB Rating Code:
1. Your name: 2. WCB Authorization #:
SSN EIN
Number and Street5. Office address:
City
7. Billing address:
State Zip Code
4. Federal Tax ID #:
B. Doctor's Information
The Tax ID # is the (check one ):
Zip CodeStateCityNumber and Street
Use this form to report continuing services. (To report the first time you treated the patient, use Form C-4. To report permanent impairment, use Form C-4.3.)
Doctor's Progress Report
4. Diagnosis or nature of disease or injury: Enter ICD10 Code: ICD10 Descriptor:
(1) (2) (3)
(4)
C. Billing Information
Relate ICD10 codes in (1), (2), (3), or (4) to Diagnosis Code column below by line.
Check here if services were provided by a WCB preferred provider organization (PPO).
C-4.2
Date(s) of Examination: ______________________________________________________________________________________________
Last First MI
Please answer all questions completely, attaching extra pages if necessary, and submit promptly to the Board, the insurance carrier and to the patient's attorney or licensed representative, if he/she has one; if not, send a copy to the patient. Failure to do so may delay the payment of necessary treatment, prevent the timely payment of wage loss benefits to the injured worker, create the necessity for testimony, and jeopardize your Board authorization. You may also fill out this form online at www.wcb.ny.gov.
2. Date of injury/illness: _____/_____/_____ 3. Soc. Sec. #:1. Name:A. Patient's Information
Last First MI
- -
Number and Street Zip CodeStateCity4. Address (if changed from previous report):
www.wcb.ny.gov C-4.2 (10-15) Page 1 of 2
Number and Street
1. Employer's insurance carrier:
3. Insurance carrier's address:Zip CodeStateCity
2. Carrier Code #: W
5. Patient's Account #:
1. Describe any diagnostic test(s) rendered at this visit: _______________________________________________________________________D. Examination and Treatment
3. Is the patient's history of the injury/illness consistent with your objective findings?2. Are the patient's complaints consistent with his/her history of the injury/illness?1. In your opinion, was the incident that the patient described the competent medical cause of this injury/illness?
Important: Form C-4 AUTH should be used to request any special medical service over $1000 or for those services requiring pre-authorization pursuant to the Medical Treatment Guidelines for the back, neck, knee and shoulder.
4. Based on your most recent examination, list changes to the original treatment plan, prescription medications or assistive devices, if any:
No Yes 1. Is patient working now?F. Return to Work
3. With whom will you discuss the patient's returning to work and/or limitations?4. Would the patient benefit from vocational rehabilitation? Yes No
with patient with patient's employer N/A
Date of injury/onset of illness:______/______/______Patient's Name:Last First MI
No Yes If yes, are there work restrictions? If yes, describe the work restrictions:
How long will the work restrictions apply? Unknown at this time15+ days8-14 days3-7 days1-2 days
No Yes 5. Based on this examination, does the patient need diagnostic tests or referrals? If yes, check all that apply:
The patient can return to work with the following limitations (check all that apply) on: _______/_______/_______ The patient can return to work without limitations on: _______/_______/_______
Kneeling
StandingSittingLiftingBending/twisting
Operating heavy equipment
Use of upper extremitiesPersonal protective equipment
Climbing stairs/laddersUse of public transportationEnvironmental conditions Operation of motor vehicles
Other (explain):
1-2 days 3-7 days 8-14 days 15+ days Unknown at this time
2. Can patient return to work? (check only one)
b.The patient cannot return to work because (explain):a.
c.
Describe/quantify the limitations: How long will these limitations apply? N/A
as needed7. When is patient's next follow-up visit? Within a week 3-4 wks 5-6 wks 7-8 wks ____ months
This form is signed under penalty of perjury. Board Authorized Health Care Provider - Check one:
Board Authorized Health Care Provider signature:/ /
5. Describe findings and relevant diagnostic test results:_______________________________________________________________________
1-2 wks
www.wcb.ny.gov C-4.2 (10-15) Page 2 of 2
2. List any changes revealed by your most recent examination in the following: area of injury, type/nature of injury, patient's subjective complaints or your objective findings: _____________________________________________________________________________________________
3. List additional body parts affected by this injury, if any: ______________________________________________________________________
All reports are to be filed with the Workers' Compensation Board, the workers' compensation insurance carrier, self-insured employer, and if the patient is represented by an attorney or licensed representative, with such representative. If the claimant is not represented, a copy must be sent to the claimant.
1. This form is to be used to file reports in workers' compensation, volunteer firefighters' or volunteer ambulance workers' benefit cases as follows:
When reporting on MMI and/or Permanent Impairment, use Form C-4.3.
Ophthalmologists use Form C-5, Occupational/Physical Therapists use Form OT/PT-4 and Psychologists use Form PS-4 for filing reports.
2. Please ask your patient for his/her WCB Case Number and the Insurance Carrier's Case Number, if they are known to him/her, and show these numbers on your reports.In addition, ask your patient if he/she has retained a representative. If so, ask for the name and address of the representative. You are required to send copies of all reports to the patient's representative, if any.
3. This form must be signed by the attending doctor and must contain her/his authorization certificate number, code letters and NPI number. If the patient is hospitalized, it may be signed by a licensed doctor to whom the treatment of the case has been assigned as a member of the attending staff of the hospital.
4. AUTHORIZATION FOR SPECIAL SERVICES - Form C-4 AUTH should be used to request any special medical service(s) costing over $1000 or for those services requiring pre-authorization pursuant to the Medical Treatment Guidelines for the back, neck, knee or shoulder.
5.
THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION
IMPORTANT - TO THE ATTENDING DOCTOR
AUTHORIZATION FOR SPECIAL SERVICES IS NOT REQUIRED IN AN EMERGENCY
6.
LIMITATION OF PODIATRY TREATMENT - Podiatry treatment is limited as defined in Section 7001 of the Education Law and Section 13-k(2) of the Workers' Compensation Law.
7.
LIMITATION OF CHIROPRACTIC TREATMENT - Chiropractic treatment is limited as defined in Section 6551 of the Education Law and the Chair's Rules Relative to Chiropractic Practice Under Section 13-l of the Workers' Compensation Law.
HIPAA NOTICE - In order to adjudicate a workers' compensation claim, WCL13-a(4)(a) and 12 NYCRR 325-1.3 require health care providers to regularly file medical reports of treatment with the Board and the carrier or employer. Pursuant to 45 CFR 164.512 these legally required medical reports are exempt from HIPAA's restrictions on disclosure of health information.
C-4.2 (10-15)
MEDICAL REPORTING
BILLING INFORMATION
Complete all billing information contained on this form. Use continuation Form C-4.1, if necessary. The workers' compensation carrier has 45 days to pay your bill or to file an objection to it. Contact the workers' compensation carrier if you receive neither payment nor an objection within this time period. After contacting the carrier, you may, if necessary, contact the Board's Disputed Bill Unit, at the Albany address indicated below, for information/assistance.
A CHIROPRACTOR OR PODIATRIST FILING THIS REPORT CERTIFIES THAT THE INJURY DESCRIBED CONSISTS SOLELY OF A CONDITION(S) WHICH MAY LAWFULLY BE TREATED AS DEFINED IN THE EDUCATION LAW AND, WHERE IT DOES NOT, HAS ADVISED THE INJURED PERSON TO CONSULT A PHYSICIAN OF HIS/HER CHOICE.
IMPORTANT TO THE PATIENTYOUR DOCTORS' BILLS (AND BILLS FOR HOSPITALS AND OTHER SERVICES OF A MEDICAL NATURE) WILL BE PAID BY YOUR EMPLOYER, THE LIABLE POLITICAL SUBDIVISION OR ITS INSURANCE COMPANY OR THE UNAFFILIATED VOLUNTEER AMBULANCE SERVICE IF YOUR CLAIM IS ALLOWED. DO NOT PAY THESE BILLS YOURSELF, UNLESS YOUR CASE IS DISALLOWED OR CLOSED FOR FAILURE TO PROSECUTE.IF YOU HAVE ANY QUESTIONS CONCERNING THIS NOTICE OR YOUR CASE, OR WITH RESPECT TO YOUR RIGHTS UNDER THE WORKERS' COMPENSATION LAW, OR THE VOLUNTEER FIREFIGHTERS' OR VOLUNTEER AMBULANCE WORKERS' LAWS, YOU SHOULD CONSULT THE NEAREST OFFICE OF THE BOARD FOR ADVICE. ALWAYS USE THE CASE NUMBERS SHOWN ON THE OTHER SIDE OFTHIS NOTICE, OR ON OTHER PAPERS RECEIVED BY YOU, IF YOU FIND IT NECESSARY TO COMMUNICATE WITH THE BOARD OR THE CARRIER. ALSO, MENTION YOUR SOCIAL SECURITY NUMBER IF YOU WRITE OR CALL THE BOARD. IMPORTANTE PARA EL PACIENTELAS FACTURAS POR SERVICIOS MEDICOS INCLUYENDO HOSPITALES Y TODO SERVICIO DE NATURALEZA MEDICA SERA PAGADO POR EL PATRONO O POR LA ENTIDAD RESPONSABLE O SU COMPANIA DE SEGUROS SEGUN SEA EL CASO; SI SU RECLAMACION ES APROBADA. NO PAGUE ESTAS FACTURAS A MENOS QUE SU CASO SEA DESESTIMADO EN SU FONDO O ARCHIVADO POR NO REALIZAR LOS TRAMITES CORRESPONDIENTES.SI USTED TIENE ALGUNA PREGUNTA, EN RELACION A ESTA NOTIFICACION O A SU CASO O EN RELACION A SUS DERECHOS BAJO LA LEY DE COMPENSACION OBRERA O LA LEY DE BOMBEROS VOLUNTARIOS O LA LEY DE SERVICIOS DE AMBULANCIAS VOLUNTARIOS DEBE COMUNICARSE CON LA OFICINA MAS CERCANA DE LA JUNTA PARA ORIENTACION. SIEMPRE USE EL NUMERO DEL CASO QUE APARECE EN LA PARTE DEL FRENTE DE ESTA NOTIFICACION, O EN OTROS DOCUMENTOS RECIBIDOS POR USTED. SI LE ES NECESARIO COMUNICARSE CON LA JUNTA O CON EL "CARRIER."TAMBIEN MENCIONE EN SU COMUNICACION ORAL O ESCRITA SU NUMERO DE SEGURO SOCIAL.
WORKERS' COMPENSATION BOARD
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD PRESENTS, CAUSES TO BE PRESENTED, OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, OR SELF-INSURER, ANY INFORMATION CONTAINING ANY FALSE MATERIAL STATEMENT OR CONCEALS ANY MATERIAL FACT SHALL BE GUILTY OF A CRIME AND SUBJECT TO SUBSTANTIAL FINES AND IMPRISONMENT.
PROGRESS REPORTS - Following the filing of Form C-4, Doctor's Initial Report, file this form within 15 days after initial report and thereafter during continuing treatment without further request, when a follow-up visit is necessary, except the intervals between reports shall be no more than 90 days.
Reports should be filed by sending directly to the WCB at the address below with a copy sent to the insurance carrier:
